With the Patient Protec­tion and Affordable Care Act now underway, more attention is being focused on patient-centered and coordinated care. As a result, primary care physicians (PCPs) are seeking new ways to organize care around patients. This includes providing in-office services that meet all of patients’ healthcare needs and/or taking responsibility for appropriate referrals. Within MaxHeath Family Medicine, the focus is on increasing our ability to address all patient health concerns by adding a diverse array of services. In addition to a patient clinic, our practice houses centers for allergy, physical medicine and rehabilitation, cosmetic medicine, and weight loss. It also offers centers for sports medicine, brain health, and mental health. By offering more services, we have successfully improved patient outcomes, as well as financial benefits for the practice. A Focus on Allergic Rhinitis & Asthma Efficient treatment of chronic conditions is important to cultivating patient-centered primary care. Nearly half of all Americans have a chronic condition, and the prevalence of such conditions continues to increase. For example, approximately 60 million Americans suffer from allergic rhinitis (AR), which often precedes the onset of chronic allergic asthma. To enhance care of chronic conditions, we must shift from simple chronic disease-state management toward prevention-focused care. In an effort to address AR, my colleagues and I implemented additional AR treatment protocols by establishing an allergy center. We work with United Allergy Services to supply allergy testing and immunotherapy to patients. For those who view their symptoms as a minor inconvenience, it is important that they avoid specific allergens. However, this avoidance approach can only work...

Although antibiotics are often used in patients with common bacterial causes of acute bronchitis, current guidelines recommend against this practice, especially for cases of uncomplicated acute bronchitis, as most are viral in etiology. Fever, purulent sputum, shortness of breath, the presence of comorbid conditions, and a provider age of 30 or younger are factors that increase the likelihood of prescribing antibiotics for acute bronchitis. Better characterization of prescribing practices in the ED is needed in order to guide efforts to reduce the inappropriate use of antibiotics. A Closer Look at Antibiotic Use My colleagues and I had a study published in the Journal of Emergency Medicine that reviewed antibiotic and bronchodilator prescribing practices of emergency physicians at two EDs in patients with acute bronchitis. The investigation aimed to characterize key factors that were associated with antibiotic prescribing practices. Specifically, we looked at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and related factors, including age, gender, chief complaint, duration of cough, and comorbid conditions. In our analysis, antibiotics were grossly overprescribed in acute bronchitis, with 74% of adults receiving these therapies. Of those who were prescribed these medications, most (about 77%) received broad-spectrum antibiotics. Prescribing practices for acute bronchitis did not decrease significantly from what has been shown in prior studies. Patients aged 50 and older and those who smoked were more likely to be prescribed antibiotics, but no other factors appeared to increase antibiotic prescribing practices. Among patients without asthma, nearly half were discharged without a bronchodilator, and more than 90% were discharged without a spacer device. Impact on Patient Care for Acute Bronchitis Although there...

The Particulars: Little is known about the impact of viral coinfections and recently discovered viruses on the epidemiology of respiratory infections (RIs) in pediatric patients. Data Breakdown: Investigators in Greece conducted an analysis in which a DNA/RNA microarray assay identified 17 viruses of viral subtypes. The assay was used to simultaneously detect viruses involved in the etiology of RIs. Two or more viruses were found in 42.5% of pediatric patients for whom viral infection was detected. The most common viruses in those with viral co-infections involved respiratory syncytial virus (RSV), including A-RSV B (27.2%), RSV-influenza (11.8%), RSV-human rhinovirus (10.6%), and para-influenza virus-influenza-RSV (5.3%). Coinfections were associated with an increased risk for hospitalization, whereas previous pneumococcal vaccination was protective. Take Home Pearls: Viral coinfections appear to play a role in a significant proportion of children with acute RI. Coinfections in this patient population may increase the severity of clinical presentation and risk for...

Previous transplants of tissue-engineered tracheas have been performed, but the tracheas used on those occasions were taken from organ donors and then reseeded with the patients’ own stem cells. In 2011, my colleagues and I performed an operation that gave a 36-year old male patient a new trachea made from a synthetic scaffold seeded with his own stem cells. The patient had been suffering from late-stage tracheal cancer. Despite maximum treatment with radiation therapy, the tumor had reached approximately 6 cm in length and was extending to the main bronchus. It was progressing and almost completely blocked the trachea. No suitable donor windpipe was available, so transplantation of a synthetic tissue-engineered trachea was performed as the last possible option for the patient. The patient made a full recovery and was discharged from the hospital following the operation. Synthetic Tissue-Engineered Trachea The international team that completed the procedure also involved Prof. Alexander Seifalian, PhD, from University College London, who designed and built the nanocomposite tracheal scaffold, and Harvard Bioscience, which produced a specifically designed, shoebox-sized bioreactor that was used to seed the scaffold with the patient’s own stem cells. The cells were grown on the scaffold inside the bioreactor for about 2 days. The scaffold was rotated while its surface was soaked with stem cells obtained from a bone marrow biopsy from the patient’s hip. The patient’s stem cells settled into the pores within the scaffold and began to grow into each other, slowly transforming from individual cells into genuine tissue. A few days after implantation of the new trachea, the patient’s own blood vessels actually started to grow into...

Adults with acute cough/lower respiratory tract infection who present with discolored sputum appear to be prescribed antibiotics more often than those with clear/white sputum, according to a recent study; however, antibiotic prescribing was not associated with recovery or benefit. Researchers of a large international study consisting of more than 3,400 patients in 13 countries investigated whether discolored sputum and feeling unwell are associated with antibiotic prescribing and whether there are benefits from antibiotic treatment for acute cough/lower respiratory tract infection. Patients with yellow or green sputum were prescribed antibiotics more than three times as frequently as those who had clear or white sputum. Antibiotic prescribing were not associated with a greater rate or magnitude of symptoms score resolution. Patients with yellow or green sputum feeling mildly unwell reported initial symptom scores of 23.3 out of 100 (patients not prescribed antibiotics) and 21.3 (patients prescribed antibiotics). After 7 days, those not taking antibiotics recorded an average symptom score of 4.3, compared with 3.9 in those taking antibiotics. The color of sputum appears to be commonly misinterpreted by both physicians and doctors to mean that antibiotics are needed. In a time when there is an alarming increase in resistance of bacteria that cause community-acquired infections, the overuse and misuse of antibiotics continues to be a public health...